07 July 2014

On Call

Every ER has its call roster, that sacred list of oracles, laying out who we can call when our patients need some service that we cannot provide. If I need a cardiologist, or a neurosurgeon or even a dermatologist for some acute emergency condition, all I need to do is ring up the operator and tell them, “This is the ER doc, I need [insert name of specialty here].” And like magic, ten minutes later, I’m talking to the local expert in whatever the patient has.

Fun fact: in the last month, I have consulted both physiatry and rheumatology from the ER.

So I was a little surprised recently when I had a patient with a nine-millimeter proximal infected ureteral stone and I called the operator to get me urology, only to be told, “There’s nobody on call for urology.” Huh? I pulled the call roster from the wall and scanned it:

Urology - No Coverage
Opthalmology - No Coverage
ENT - No Coverage
Plastics - No Coverage

Wow. That’s a lot of specialties that we don’t have access to. For the record, we are not some little 40-bed rural hospital. We are a 100,000 visit facility that styles itself a “regional medical center” and accepts transfers from a large catchment area. And evidently there are multiple services we no longer offer, at least not in the evening and at other inconvenient times.

Why is this? Because these local specialists have decided, as individual groups, that ER work is taxing, difficult, low-paying and high-risk. (Tell me about it.) And one by one, they have decided to quit. They just said, “Nope, not covering the ER any more.” And our hospital is not the only one facing this problem. It is, in fact, probably the biggest challenge facing emergency medicine nationwide.

Now I get it. I die a little inside when I have to call in a board-certified urologist at 0300 to put in a foley on some poor 87-year-old in urinary retention, after all my nurses and I fail to get it in. I really hate inconveniencing them, especially when it’s something that I maybe should have been able to handle myself. But that’s the life of an ER doc and I am pretty inured to it by this time. (Maybe I’m all the way dead inside?)

Which is why I was kinda incensed by the recent post over at Kevin’s site: Should Doctors be paid overtime for taking call?

The cardiologist writing that post painted a beautiful picture of how much call sucks, and I get it. I know the absence of call played into my decision to pursue Emergency Medicine as a career. But the question posed, in the context of the current situation, feels almost like blackmail: “Pay me or I’m gone, too.”

The history here is that being on call has pretty much always been a service that is part of the practice of medicine. No matter your specialty, if your patient got sick at night, you would be called in to deal with it. As the number of patients without established doctors grew, most hospitals had “no-doc” coverage rotating for unassigned patients. When you are on call, you don’t get paid for phone calls, but you do get paid if you have to come in and see or admit a patient (presuming they have insurance). In the old days call may have been a practice-growing revenue stream, but for a long time now it’s been a poorly-reimbursed time suck for most specialists.

A growing trend we are seeing nationally is for specialists to demand — and receive — reimbursement from the hospital just to be on call. Our hospital being a skinflint catholic shop responsible steward of resources told the specialists to pound sand, which led to their absenting themselves from the medical staff and call roster. But many hospitals, especially those in highly competitive markets, have started to pony up and pay docs to take call.

The math of this is really challenging. Once you are paying one group to be on call, it’s hard to justify not paying all of them. The most demanding, in my understanding, have been ENT, Hand, Neurosurgery, Optho, Plastics and Urology. The going rate seems to be about $1,000 per night, though YMMV. Ironically, these are among the least-consulted and highest-paying surgical subspecialties, which further creates an unseemly impression of physician greed. But if you meet their extortionate demands, that winds up costing the hospital $6,000 a day, 365 days a year, or about $2.2 million annually, assuming all the other specialists don’t pile on with their own demands. That’s for nothing, mind you: for being “available” without doing any work. No calls? You still bank nearly as much as I did for a busy shift of seeing patients.

And there is a tendency to see the hospital as the font of endless dollars, but hospitals are in rough shape. Their typical profit margin is in the 2-4% range, frequently dropping to zero or negative when the economy dips a bit, and under relentless pressure from medicare and insurers to accept lower reimbursements. While it’s tempting to look at the gross revenue and assume that of that $50-100 million, "surely the hospital can afford to pay to keep me on call,” in reality that is not the case.

The grim reality is this: we pay more than any other society for health care (and get less for it). There is no new money coming into the system; quite the opposite. When specialists demand extra money for a service that they have previously provided not for free but based on only professional reimbursement, that’s going to pull resources from somewhere else. Maybe it’ll be fewer ER nurses. Maybe it’ll be fewer staffed inpatient beds. It’s going to come out of the budget somewhere.

Which is why I am kind of glad our facility held firm in the face of the extortion of the surgical specialists. These guys all make ~$300K a year. I feel that if I (also well paid) have to see folks at 3am as part of my gig, they should too, and not command some premium for the service.

Am I bitter? Yes, a little. But much of that comes from the fact that I see the consequences of the specialists who opt out of call. I feel like they are still really well paid and are shirking their duty to the community and to the patients. That patient with the kidney stone? I had to transfer him out of our gleaming $500 million hospital to the county facility where a resident could take care of him. His care suffered because of the greed and entitlement of the local specialists; this wasn’t the first or last time I will encounter this problem. I don’t like seeing patients used as pawns, and I get a little enraged when local doctors jeopardize patient care over economic concerns. As I see more and more physician practices being bought by hospitals, in part to secure their call networks, I see these guys digging their own graves.

So, no, I don't favor paying specialists for being on call. Suck it up, guys, and do the right thing for your patients. Structure your practices to make call suck a little less, maybe. I empathize. When I'm sitting in a mostly empty ER at 4AM, I'm not getting paid either. But overall, we both make enough to have pretty good lives and still not opt out of caring for those who are unlucky enough to get sick at inconvenient times.